Nurse Reynolds caring for a client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to:
A. Call the physician.
B. Place the tube in a bottle of sterile water.
C. Immediately replace the chest tube system.
D. Place a sterile dressing over the disconnection site.
Correct Answer: B. Place the tube in a bottle of sterile water.
If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. Anchor thoracic catheter to the chest wall and provide an extra length of tubing before turning or moving the patient. Prevents thoracic catheter dislodgement or tubing disconnection and reduces pain and discomfort associated with pulling or jarring of tubing.
Option A: The physician may need to be notified, but this is not the initial action. Observe for signs of respiratory distress. If possible, reconnect thoracic catheter to tubing or suction, using clean technique.
Option C: The system is replaced if it breaks or cracks or if the collection chamber is full. Pneumothorax may recur, requiring prompt intervention to prevent fatal pulmonary and circulatory impairment.
Option D: Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. If the catheter is dislodged from the chest, cover the insertion site immediately with petrolatum dressing and apply firm pressure. Notify the physician at once.
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